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Home My Public Portal About4819 CAMELLIA AVE_Plumbing__ .WORKERS'COMPENSATION DECLARATION 76AB17M (' 1 hereby affirm that I have acertificate of consent to self cEstr (z-eo) APPLICATION FOR PLUMBING PERMIT insure„or a certificate of Workers'Compensation Insurance,or 'a certified copy thereof(Sec.3800,Lab.qqC.) ' e i COUNTY OF LOS ANGELES, ////J, BUILDING AND SAFETY .Policy No. 07Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING,/ // r. L "T2in ADDRESS (�IT Q�� J t Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE dpa��t7{ LOU + I WATER CLOSET LOCALI V Dated Applicant ""`' /��yn L/rte NEAREST I BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' D COMPENSATION INSURANCE SHOWER' - OWNE�, Orotja (4h17J012 06 jehOut--) L (This section need not be completed if the work involved LAVATORY MAIn I ADDRESS // iL + -e -rL i by the permit is for one hundred dollars ($I00) or less.) SINK CITY ,{l L Ez"�.NO. "' '' a I certify that in the �G � J 0 y performance of the work for which this ' DISHWASHER �-� Qqr rff in �^/� r' permit is issued, I shall not employ any person in any manner CONTRACTISR C. / Iri so as to become subject to theprkerq�fom0,�� tion-y��wµ`{�" CLOTHES WASHER ry L Date 1COo4 Applicant C J"l�rf`.rf,+i'1 A BYO hORl7V ADDRESS / Pn /' ee 2 SWIMMING POOL RECEPTOR U qA NOTICE TO APPLICANT: If, after making this Certificate otr CITY (�_)f_4,7q4 TEL.N /(� [) a Exemption, you should 'become subject to the Workers' LAWN SPRINKLER SYSTEM STATE // (� LIC. to provisions of the Labor Code, you must forth- LICENSE NO..33,36 �O LAS {� ��r. (p to with comply with such provisions or this permit shall be WATER HEATER deemed revoked. / GAS SYSTEM 3 OUTLETS EO RICTJ�Ip. P C SED B LICENSED CONTRACTORS DECLARATION OUTLETS OVER (l%y Cy�aJ/ `' I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL /��yl� VALIDATION ness and Professions Code, and my license is in full force and DATE W V effect. FINAL License Numbe 36Vi Lie.ClassC By %n Contractor Un &te /_7 0aez /� ✓ + �� F am exempt from the licensingrequirementsas I am a Plan Check f86 licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Gj Q Lie.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address @2566A License Law for the following reason (Section.703 1.5, Busi. City Tel.No. ness and Professions Code): # . e e o 0 5 EI, as owner of the property, am exclusively contracting with licensed contractors to construct the project - 2 ^ ^ c3{6 5.0 (Section 7044, Business and Professions Code). ^ Oe31a506 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency O 1.08-82 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). ' Lender's Name Lender's Address , 1 certify that I have read this application and state that the ' above information is correct. I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this, County to enter upon the above-mentioned proper t y.for, Spec ion rposes. Signature of Pet ittee Date /�Y P •.r WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I hove a certificate of consent to self 76A657A PERMIT insure, or a certificate of Workers' Compensation Insurance, CE 817(REV, 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES :BUILDING AND SAFETY Policy NCompany Certified ified copy is hereby furnished. r�. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING R /� a ❑ Certified copy is filed with the county building'inspec- ADDRESS (int-ALWA tion department. NUMBERFIXTURE OR ITEM ?d FEE Date Appligant WATER CLOSET NEAREST / CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. \. COMPENSATION INSURANCE SHOWER t.XL 1 (This section need not be completed if the work-involved by MAIL '1 the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS ( I Z J' CQv I certify that in the performance of the work for this - .12Y_ GAltq permit is issued, I shall not emp ya ny person i an m nr e�r� SINK CITY MpN'G'g L`O TEL. N .26 ""J so as to become subjeU to the orkers'.6ompe a on ws. DISHWASHER - - ^/ CONTRACTOR Date __ 6 Applicant CLOTHES WASHER l NOTICE TO APPLICANT: If, after eking this' rtificate of ADDRESS Exemption, you should become subject to. t Workers SWIMMING'POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM " CITY / TEL. NO. with comply with such provisions or this permit shall be STATE !. LIC. deemed revoked. WATER NEATE LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION O.DISTRICT Ni�f OCESSED 8Y 1 hereby affirm that I am licensed under provisions of Chapter 9 GAS'SYSTEM OUTL 5 , (commencing with Section 7000) of Division 3 of the Business OUTLETS'OVER' and Professions Code,and my license is in full force and effect. 15 PER SYSTEM1 DATE VALI TION License,Number Lir Class d. FINAL A O Contractor Date BY V ❑ I am exempt under Sec 6 N B.BP.C. for this reason plan Check feeD ? Signature Date: V 226-9.2A PLUMBING PERMIT ISSUING FEE$ - TOTAL FEE }'j' e s e'o a 5 Plan check applicant I a • 1 6 50 SINGLE FAMILY �� . HOME OWNER-BUILDER DECLARATION Name � �., J 1 - a e '.6 500 I hereby affirm that I am exempt from the Contrractor's License. �aL) , $ `�-g 5 Law for the following reason (Section 7031.5, Business and Address `��'� / `> 2 J r 1" Q Professions Code): by "10N 1FgLLv Tel. N .21 UL.I I, as owner of the property, will do the work and the - // structure is not intended or offered for sale (Section D 7044, Business and Professions Code).' - CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Seca 3097, Civ. C.). - Lender's Name - lender's Address I certify that I have read this application and slate that the D above informationis correct. I agree to comply with off County ordinances and State laws regulating Plumbing, and hereby uthorize represents es of this County to enter upon the bove-menl,oped pr trty for mspection'purposes, QC— SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Perm, lee Date • COUNTY OF LOS ANGELES TEMPLE CITY N 0506 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1205110008 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0468 EXT: ILEGAL ID: FEES PAID BUILDING ADDRESS: 1 ITR: 14467 LT: 49 4819 CAMELLIA AV I (FRE DESCRIPTION: QUANTITY: DIM: AM0UNT: 1 TEMP CA 917804241 (ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: 1 8589-015-026 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: AS LOCALITY: TEMPLE CITY CAI 1 125 LAVATORIES/SINKS 1.00 FIX 16.20 ITENANT: I TOTAL FEES 44.00 (ISSUED ON: PROCESSED BY: PLAN BY: (05/11/12 SR I I I I OWNER: TEL. NO: F�AL DATE PIA�L BY: CODE: 1ARVISO LAWRENCE J;NARGIE M 11128 VERA CRUZ ST IMBLO 906402551 IDESCRIPTION OF WORK BATHROOM REMODEL VANITY C GEOUT 1APPLICANT: TEL. NO: ITONY'S REFRIGERATION (562) 948-4194- 18815 DUNLAP CROSSING (SPECIAL CONDITIONS: IRE PICO RIVERA 90660 CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE TONY'S REFRIGERATION (562) 948-4194- 1 18815 DUNLAP CROSSING LIC. NO (UNDER SLAB WORK 1PICO RIVERA CA 90047 610858 * 1 1WATER SERVICE PLASTIC Y/N METAL Y/N (ARCHITECT OR ENGINEER: TEL. NO: - 1R0UGH PLUMBING LIC. NO: I IGAS PIPING 11 IGAS VENT I ~ 11 IH0T WATER HEATER '• PLUMBING FIXTURES LAWN SPRINKLERS GAS TEST (UTILITY COMPANY NOTIFIED 111 I 11I I 1 ICWV � 1 I GRAY WATER SYSTEM I I � I 111 I I 111 I 111 I I I I I I I I I I I I I I I I I I I I I I * ADDITIONAL DATA ON PILE I I I I I (REPORT ID: DPR263 ROUTE T0: B50508 I I I I